Healthcare Provider Details

I. General information

NPI: 1306119086
Provider Name (Legal Business Name): DAVID'S LOFT CLINICAL PROGRAMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2012
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2641 MARYLAND AVENUE
BALTIMORE MD
21218
US

IV. Provider business mailing address

2641 MARYLAND AVENUE
BALTIMORE MD
20715
US

V. Phone/Fax

Practice location:
  • Phone: 410-800-4226
  • Fax: 410-387-7637
Mailing address:
  • Phone: 410-800-4226
  • Fax: 410-387-7637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC2650
License Number StateMD

VIII. Authorized Official

Name: MR. DAVID H. THOMPSON JR.
Title or Position: CEO
Credential:
Phone: 410-800-4226